Mental health detentions at record high, says CQC

The number of detentions under the Mental Health Act is now at the highest on record, according to a report from the Care Quality Commission.

In 2012-13, the Act was used 50,408 times to detain or treat people using compulsion, up 14% on 2007-08 when the figure was 44,093.

In its report the CQC was critical of the way some patients end up detained, with people told they are simply going for a “cup of tea” or “for a nice chat”.

It also criticised the fact more than three-quarters of mental health wards visited by inspectors have “blanket rules” for all patients. These stop people doing things such as calling home, using the internet, accessing kitchens or using an outdoor space.

It said such practices have “no basis in law or national guidance” and are “unacceptable”.

In 2012-13, some 34,650 patients were detained on admission and a further 14,249 were detained after going to a mental health hospital on an informal basis.

The CQC said it was a “serious cause for concern” that so many people admitted informally for care and treatment are subsequently detained.

Inspectors found that in one region, some patients who arrived on the ward on an informal basis, or under the purported authority of the Mental Capacity Act, “appeared to be unaware of where or for what purpose they had been brought there”.

“We heard of examples of patients being told they were coming into hospital ‘for a nice chat’, ‘a cup of tea’ or ‘to see a doctor’.”

The CQC reported a rise in short-term “holding powers” for such informal patients, who would otherwise discharge themselves.

It said: “Their subsequent distress on realising their actual situation as an admitted inpatient led to them trying to leave, and ‘holding powers’ being invoked.

“Subterfuge or euphemism should never be used to admit a patient into hospital. Such practices breach the guiding principles and specific guidance of the code of practice, and must be open to legal challenge in any individual case as unlawful deprivation of liberty.”

The report said that, overall, there are “nationally recognised problems with access to care during a mental health crisis”.

This means patients can end up in more restrictive types of care and treatment due to pressure on other services, such as being able to access a GP in an emergency or call a mental health practitioner outside normal working hours.

There is also an ongoing issue with police detaining people in custody because there is nowhere else readily available for them to go.

“In one area police told us that 41 young people had been detained in police cells over the previous year; the youngest was 11,” the report said. “This is unacceptable.”

Inspectors found the use of “blanket rules” on wards was “widespread”.

In 46% of cases reviewed the reason given for the blanket rules was ‘hospital policy’ and in 13% of cases no reason was given.

The most common restrictions related to using the internet and mobile phones, smoking, and access to secure outdoor space and communal rooms. There were also examples of “rigid” visiting times, people not allowed food outside set meal times, no choice of food and no ability to get drinks.

During some inspections, inspectors found that the physical health of patients were not met and basic standards were not being met in some cases.

One patient told inspectors “that for the week that she had been an inpatient she had no access to her glasses, her dentures or a change of clothes. She also told us she had not changed her underwear for that period of time, but did not want to disturb the nurses as they seemed busy”.

Inspectors found plans had been made for her to get clean clothes, her dentures and glasses but these were not acted on by staff.

The report also raised issues over staffing levels, saying poor staffing meant patients’ trips out were cancelled, such as to the opticians or cinema.

Poor staffing was also found to “exacerbate problem behaviour or otherwise impede the process of recovery” for patients.

In the three high-security hospitals – Broadmoor, Rampton and Ashworth – night-time confinement had been introduced or piloted, partly as a way to cut costs.

This means patients were locked in their rooms overnight and from a certain time, such as 9pm.

While the hospitals said the pilots were successful, several patients told inspectors they felt “like they were now in prison” and were worried how they would get out in a fire.

The report found examples of excellent care but concluded: “It should be a source of considerable concern to the health and social care system in this country that use of the Mental Health Act continues to rise – despite the objectives of the national mental health policy and the investments in community services of recent years.

“People should have access to the right services at the right time and for the right reasons with detention never being the consequence of local system failures in facilitation of timely and appropriate access to care.”

'Some services are still coming to terms with advance decisions and advance statements. Our Second Opinion Appointed Doctors (SOADs) have been approached by clinicians who are unsure whether they might get a second opinion to consider ECT when a patient has made an advance refusal of consent. They cannot. A SOAD could not authorise treatment in such circumstances and there would be no point in arranging the visit. Similarly, SOAD visits have been cut short when it became clear that a valid advance decision was in place refusing consent to ECT.'

The above appears on page 55 of the CQC’s ‘Monitoring the Mental Health Act in 2012/13’ report (the pdf you can download from the link at the end of this article).

Interestingly, it not only mentions both advance decisions and advance statements (the difference between the two, seemingly causing conceptual issues for many HCPs) but it also separates ‘an advance refusal of consent’ from ‘a valid advance decision was in place’.

It is remarkable, how many HCPs, even some senior consultants, seem confused by the legal ‘rules’ about refusals of treatment, something I’m nagging a lot of people about ! The CQC appears to understand ‘what is what’ re the law about consent, however (you can tell, by the separation in their writing between ‘an advance refusal of consent’ and ‘a valid advance decision refusing consent’).

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